Cardiac Services Documentation Requirements - JE Part A
Cardiac Services Documentation Requirements
- General Outpatient
- Implantable Automatic Defibrillator (ICD)
- Pacemaker
- Single Photon Emission Computed Tomography (SPECT)
General Outpatient
It is expected that patient's medical records reflect the need for care/services provided. The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered. They may include:
- Anesthesia records, if applicable
- Recovery room records, if applicable
- MAR, if applicable
- Support medical necessity
- Support LCD and NCD requirements, if applicable
- Results of prior testing to support medical necessity, if applicable
Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part A Claim Review for detailed information about each of these contractors.
Documentation Submission
Once a provider compiles all the necessary documentation, it is important to submit them to the appropriate contractor according to the request received. Select the request below to view the appropriate submission instructions.
- Noridian Medical Review - Additional Documentation Request (ADR)
- Comprehensive Error Rate Testing (CERT) - CID Request
- Level One Appeal - Redetermination Request
Implantable Automatic Defibrillator (ICD)
It is expected that patient's medical records reflect the need for care/services provided. The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered. They may include:
- Signature logs and Signature Attestation Statement should be submitted when physician and/or clinician signatures are illegible
- If an electronic health record is used, the Electronic Order Signature Process Form should be submitted to verify provider's Electronic Ordering System is secure
- History and physical, progress notes, office visit notes, cardiology consultations and all other pertinent medical records
- Documented episode of cardiac arrest due to ventricular fibrillation (VF), not due to a transient or reversible cause
- Documented sustained ventricular tachyarrhythmia (VT), either spontaneous or induced by an electrophysiology (EP) study, not associated with an acute myocardial infarction (MI) and not due to a transient or reversible cause
- Documented familial or inherited conditions with a high risk of life-threatening VT, such as long QT syndrome or hypertrophic cardiomyopathy
- Coronary artery disease with a documented prior MI, a measured left ventricular ejection fraction (LVEF) = 0.35, and inducible, sustained VT or VF at EP study
- Documented prior MI and a measured LVEF = 0.30
- Patients with ischemic dilated cardiomyopathy (IDCM), documented prior MI, NYHA Class II and III heart failure, and measured LVEF = 35%
- Patients with non-ischemic dilated cardiomyopathy (NIDCM) >9 months, NYHA Class II and III heart failure, and measured LVEF = 35%
- Patients who meet all current CMS coverage requirements for a cardiac resynchronization therapy (CRT) device and have NYHA Class IV heart failure
- Patients with NIDCM >3 months, NYHA Class II or III heart failure, and measured LVEF = 35%
- Cardiogenic shock or symptomatic hypotension while in a stable baseline rhythm
- Had a CABG or PTCA within the past 3 months
- Had an acute MI within the past 40 days
- Clinical symptoms or findings that would make them a candidate for coronary revascularization
- Any disease, other than cardiac disease (e.g., cancer, uremia, liver failure), associated with a likelihood of survival less than 1 year
- Angiography
- Echocardiography
- Electrocardiogram (ECG)
- Electrophysiology (EP) studies
- Holter monitor readings
- Nuclear stress tests
- Radionuclide scanning
- Telemetry strips
- When no official imaging report is available, the following components must be present within medical records: date(s) imaging was completed, type(s) of imaging/exam and detailed findings
- If rationale is missing from record, use of a dual chamber or bi-ventricular device will be denied
Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part A Claim Review for detailed information about each of these contractors.
Documentation Submission
Once a provider compiles all the necessary documentation, it is important to submit them to the appropriate contractor according to the request received. Select the request below to view the appropriate submission instructions.
- Noridian Medical Review - Additional Documentation Request (ADR)
- Comprehensive Error Rate Testing (CERT) - CID Request
- Level One Appeal - Redetermination Request
Pacemaker
It is expected that patient's medical records reflect the need for care/services provided. The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered. They may include:
- Signature logs and Signature Attestation Statement should be submitted when physician and/or clinician signatures are illegible
- If an electronic health record is used, the Electronic Order Signature Process Form should be submitted to verify provider's Electronic Ordering System is secure
- History and physical, progress notes, office visit notes, cardiology consultations and all other pertinent medical records
- Non-reversible symptomatic bradycardia due to sinus node dysfunction
- Non-reversible symptomatic bradycardia due to second degree and/or third degree atrioventricular block
- Documentation to support appropriate KX or SC modifier
- Angiography
- Echocardiography
- Electrocardiogram (ECG)
- Electrophysiology (EP) studies
- Holter monitor readings
- Nuclear stress tests
- Radionuclide scanning
- Telemetry strips
- When no official imaging report is available, the following components must be present within medical records: date(s) the imaging was completed, type(s) of imaging/exam and detailed findings
Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part A Claim Review for detailed information about each of these contractors.
Documentation Submission
Once a provider compiles all the necessary documentation, it is important to submit them to the appropriate contractor according to the request received. Select the request below to view the appropriate submission instructions.
- Noridian Medical Review - Additional Documentation Request (ADR)
- Comprehensive Error Rate Testing (CERT) - CID Request
- Level One Appeal - Redetermination Request
Single Photon Emission Computed Tomography (SPECT)
It is expected that patient's medical records reflect the need for care/services provided. The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered. They may include:
- Signature logs and Signature Attestation Statement should be submitted when physician and/or clinician signatures are illegible
- If an electronic health record is used, the Electronic Order Signature Process Form should be submitted to verify provider's Electronic Ordering System is secure
- If the order for clinical diagnostic test be unsigned, there must be medical documentation (e.g. a progress note) by treating physician that he/she intended clinical diagnostic test to be performed
- Documentation showing intent that test be performed must be authenticated by author via a handwritten or electronic signature
- Most recent history and physical and/or physician clinic/progress notes pertaining to diagnosis/reason the SPECT scan was completed
- Nurse notes, consultation reports, emergency room records, disposition/discharge reports, if applicable
- Stress fracture
- Spondylosis
- Infection (e.g., discitis)
- Tumor (e.g., osteoid osteoma)
- Analyze blood flow to an organ, as in case of myocardial viability
- Differentiate ischemic heart disease from dilated cardiomyopathy
- SPECT scans may not be used following an inconclusive fluorodeoxyglucose (FDG)- positron emission tomography (PET) performed to evaluate myocardial viability
Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part A Claim Review for detailed information about each of these contractors.
Documentation Submission
Once a provider compiles all the necessary documentation, it is important to submit them to the appropriate contractor according to the request received. Select the request below to view the appropriate submission instructions.
- Noridian Medical Review - Additional Documentation Request (ADR)
- Comprehensive Error Rate Testing (CERT) - CID Request
- Level One Appeal - Redetermination Request
View the Outpatient Prospective Payment System (OPPS) webpage for additional information and resources.
Documentation Requirements Disclaimer
The documentation requirements contents/references provided within this section were prepared as educational tools and are not intended to grant rights or impose obligations. Use of these documents are not intended to take the place of either written law or regulations.
The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered.
Important that physician intent, physician decision and physician recommendation to provide services derived clearly from the medical record and properly authenticated.
The submission of these records shall not guarantee payment as all applicable coverage requirements must be met.
